Health History

Inquiry history taking by questioning to take a history

★ The contents of inquiry 1 general data ﹡ 2 chief complaints ﹡ 3 present illness 4 past medical history 5 systems review 6 personal history 7 marital history 8 menstrual history 9 childbearing history 10 family history

1 General Data Name Native place Sex Working unit Age Date of admission Race Date of record Occupation Marriage Address

2 Chief Complaints The chief complaints should constitute in a few simple words: symptom(s) plus time. The main reasons why the patient consults a doctor. The chief complaints should be stated as nearly as possible in the patient’s own words.

For example: ▲ sore throat, high fever for two days ▲ chill, fever, right chest pain, cough for three days ▲ recurrent epigastric pain for eight years, it has been getting worse over the past two weeks.

The chief complaint should not include diagnostic terms or disease entities such as: diabetes heart disease hypertension

Diabetes: polydipsia polyphagia polyuria weight loss Heart disease: palpitation short of breath Hypertension: dizziness headache

3 History of Present Illness (1) Onset and Duration (2) Features of chief symptoms (3) Causes of illness and Precipitating factors (4) Progression of the illness (5) Accompanied symptoms (6) Previous treatment (7) General condition

(1)Onset and Duration sudden: acute myocardial infarction acute pancreatitis insidious: cancer of the colon

Duration minutes hours days months years for example: Severe precardiac pain for twenty minutes --acute myocardial infarction

(2) Features of Chief Symptoms for example: pain location frequency duration intensity quality (blunt colic distention burning ) radiation alleviating and aggravating factors.

(3) Causes of Illness and Precipitating Factors causes: infection trauma precipitating factors: climate change environmental change emotive change irregular meals

(4) Progression of the Illness the development of main symptom and appearance of new symptoms. pulmonary emphysema(short of breath) severe dyspnea pneumothorax angina pectoris (severe chest pain) myocardial infarction

(5) Accompanied Symptoms for example: diarrhea accompanied by vomiting food poisoning diarrhea accompanied by tenesmus dysentery

(6) Previous Treatment medication dosage effects (7) General Conditions mental state after illness appetite body weight sleeping urine bowel movement

4 Past Medical History past health status past illness mainly indicate infections contagious diseases such as Tuberculosis(TB) Hepatitis

any illness relevant to present illness, such as operations injuries vaccinations allergies

5 Systems Review (1) respiratory system (2) cardiovascular system (3) gastrointestinal system (4) urinary systems (5) hematopoietic system (6) endocrine system (7) neurological system (8) musculoskeletal system

(1) Respiratory System cough character of the cough dry cough pleurisy bronchial TB productive cough chronic bronchitis bronchiectasis

time of cough morning and going to bed at night: chronic bronchitis at night: pulmonary congestion due to left heart failure or mitral stenosis

Sputum: amount consistency color hemoptysis: amount color dyspnea: nature intensity onset of time chest pain location nature intensity duration …

(2) Cardiovascullar System palpitation: time the pain of precordial region feature extent radiation precipitating factors edema: location lower extremities congestive heart failure breath lessness: on exertion heart failure

(3) Gastrointestinal System vomiting: time precipitating factors the contents of vomiting hematemesis: amount color hematochezia: diarrhea constipation

(4) Urinary Systems amount of urine increased polyuria diminished oliguria anuria bladder involvement urinary frequency urgency burning on urination

(5) Hematopoietic System fatigue lassitude palpitation dizziness anorexia

(6) Endocrine System diabetes mellitus typical symptoms polyguria polydipsia polyphagia weight loss

(7) Neurological System common symptoms convulsion vertigo headache paresthesia paralysis

(8) Musculoskeletal System muscular pain swelling deformity disability of joints

6 Personal History place of birth current residence educational background economic status living conditions professional working conditions

habits and hobbies: such as sleeping eating drinking smoking alcohol consumption amount duration drugs (including sedative or narcotics)

7Marital History married or unmarried marriage age relations of couple

8 Menstrual History age of onset interval between periods duration amount of flow date of last menstrual period(LMP) age of menopause

record menstrual history as follows menstrual duration Age of LMP onset interval between periods

9 Childbearing History age of pregnancy and childbirth times of artificial or natural abortions stillbirth operative delivery puerperal fever method of family planning

10 Family History ages and health status of parents family history of illness similar to patients family incidence of infectious diseases TB hepatitis genetic illness such as hemophilia

★ The methods and skills of inquiry 1 The organization of inquiry introduction introduce yourself and explain your role the body of interview chief complaints present illness past medical history the end of interview

2 The sequence of inquiry to begin with complaints for example: a patient complains he has a headache you can ask When did you begin to have headache? Have you ever had this kind of headache before? Where is the pain? How long dose the pain last?

3 The types of question to begin with general questions for example: what brings you here today? What’s the matter with you? Tell me about your general health.

4 To avoid leading questions for example: Your chest pains have radiated to left arm? Right? 5 To avoid medical terms and jargon for example: palpitation epistaxis tenesmus

6 Documentation you must document the information given to you by the patient If the patient tell you I have hypertension, you should ask patient How did you know that you had hypertension?

Summary Inquiry ★ The importance of inquiry ★ The contents of inquiry ﹡ chief complaints ﹡ history of present illness ★ The methods and skills of inquiry